Bronchoscopy is a vital diagnostic and therapeutic procedure that has become an indispensable tool in modern medicine.
This minimally invasive technique, which involves the insertion of a flexible or rigid bronchoscope into the patient’s airways, allows healthcare professionals to visualize and assess the trachea, bronchi, and bronchioles in real time.
The procedure plays a crucial role in diagnosing various respiratory diseases, such as lung cancer, chronic obstructive pulmonary disease (COPD), and infections, as well as guiding treatments like biopsies, removal of foreign bodies, and stent placement.
In this article, we will provide an overview of the bronchoscopy procedure, delving into its significance, purpose, and various techniques employed by healthcare professionals. We also compiled a list of practice questions that cover key aspects of this procedure.
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What is a Bronchoscopy?
A bronchoscopy is a medical procedure that allows a healthcare provider to visually examine the airways of the lungs, including the trachea and bronchi.
This examination is typically performed by a pulmonologist or a thoracic surgeon using a bronchoscope, which is a thin, flexible tube with a light and a camera on its end.
The bronchoscope is inserted through the patient’s nose or mouth and is gently guided down the throat into the airways.
The procedure can be performed for various reasons, such as:
- Diagnostic purposes: Bronchoscopy can help identify various lung conditions, including infections, tumors, inflammation, bleeding, or other abnormalities in the airways.
- Collection of tissue samples: During the procedure, small samples of lung tissue (biopsies) or fluid (bronchoalveolar lavage) may be collected for further analysis and testing.
- Treatment: Bronchoscopy can be used to remove foreign objects, clear mucus plugs, control bleeding, or deliver medication directly to the lungs.
There are two main types of bronchoscopy:
- Flexible bronchoscopy: The most common type, which utilizes a flexible bronchoscope. It is usually performed under local anesthesia with sedation to keep the patient comfortable.
- Rigid bronchoscopy: Involves a rigid, metal bronchoscope and is typically performed under general anesthesia. It is less commonly used but may be necessary for certain situations, such as removing large foreign objects or controlling severe bleeding.
Overall, bronchoscopy is a valuable diagnostic and therapeutic tool for evaluating and managing respiratory conditions.
The procedure is generally considered safe, but some potential risks include bleeding, infection, or a reaction to anesthesia.
Read our other guide that explains more details about the differences between flexible and rigid bronchoscopy procedures.
Respiratory Therapist’s Role During a Bronchoscopy
The involvement of respiratory therapists in bronchoscopy procedures can vary depending on the specific healthcare setting.
Generally, their primary responsibilities are to assist in the procedure, ensure the proper functioning of equipment, and maintain the patient’s stable condition throughout the process.
Before the Procedure
Prior to the procedure, respiratory therapists help determine if a bronchoscopy is necessary by identifying potential indications, such as retained secretions or foreign body obstructions.
They verify the physician’s order or protocol, review the patient’s medical record for contraindications and potential hazards, and confirm informed consent has been obtained.
RTs are responsible for preparing and checking all necessary equipment to ensure it functions correctly. They also develop a plan to maintain adequate oxygenation during the procedure.
If necessary, RTs can evaluate patients for bronchospasm and administer aerosolized bronchodilators before the procedure begins.
During the Procedure
Throughout the bronchoscopy, respiratory therapists closely monitor the patient’s vital signs and promptly identify and address any adverse reactions. They continue to administer oxygen as required and assist with patient positioning for optimal results.
They also help with the utilization of accessories, such as bite blocks, oral airways, nasopharyngeal tubes, biopsy forceps, and brushes.
After the Procedure
Following the bronchoscopy, respiratory therapists provide essential post-procedure care, including assisting patients with deep breathing and coughing exercises to clear secretions, and administering supplemental oxygen as needed.
They continue monitoring the patient’s vital signs and promptly report any changes to the physician. Furthermore, they are responsible for documenting all aspects of care in the patient’s medical record.
Bronchoscopy Practice Questions
1. What is flexible bronchoscopy used for?
It can be used for diagnostic and therapeutic purposes; however, it is most often indicated to help with the diagnosis of pulmonary diseases.
2. What is the goal of sedation during a bronchoscopy?
It improves the patient’s comfort during the procedure.
3. The continuous monitoring of what is important during a bronchoscopy procedure?
The monitoring of oxygenation and hemodynamic stability is important.
4. What are the most commonly used diagnostic procedures in flexible bronchoscopy?
BAL, biopsy, and TBNA.
5. BAL obtains samples from what?
6. Needle aspiration has a role in sampling mediastinal lymph nodes to diagnose what?
Lung cancer, sarcoidosis, and some infectious processes.
7. A biopsy has value in the diagnosis of what?
Infiltrative pulmonary diseases
8. What is often used along with a flexible bronchoscopy?
Various thermal ablation techniques
9. When using thermal ablation techniques, what is the most important thing to remember?
You should ensure a low FiO2 environment before the use of any thermal ablative therapy.
10. When can airway stenting be used to maintain airway patency?
It is used after the dilation of any obstructed major airways, and it’s important to recognize the difference between silicone and metallic stents.
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11. What is bronchial thermoplasty?
It’s a novel bronchoscopic technique for patients with steroid-dependent asthma.
12. What is being studied in the management of patients with severe emphysema as a minimally invasive lung volume reduction therapy?
Endobronchial valves and coil placement
13. Who plays a vital role in assisting before, during, and after bronchoscopy?
14. How does a respiratory therapist help with a bronchoscopy procedure?
There are many aspects to this role, but they include ensuring appropriate documentation (e.g., physician’s order), preparing the patient and the equipment, patient monitoring, and responding to adverse events.
15. What special considerations should be made when performing a bronchoscopy on mechanically ventilated patients?
Patients on the ventilator are more susceptible to adverse events. These considerations include ensuring adequate ventilation and gas exchange before, during, and after the procedure.
16. What are the clinical situations where flexible bronchoscopy would be indicated?
Hemoptysis, wheezing and stridor, pulmonary infiltrates, unexplained lung collapse, suspected or known bronchogenic carcinoma, mediastinal and hilar lymphadenopathy, lung transplantation, endotracheal intubation, evaluation of foreign body aspiration, unexplained superior vena cava syndrome, unexplained vocal cord paralysis, suspected fistulas, and treatment of refractory asthma.
17. What are the absolute contraindications for flexible bronchoscopy?
Refractory hypoxemia, lack of patient cooperation, lack of skilled personnel, lack of appropriate equipment and facilities, unstable angina, uncontrolled arrhythmias, increased intracranial pressure, and uncorrectable bleeding diathesis.
18. What are the relative contraindications for flexible bronchoscopy?
Unexplained or severe hypercarbia, uncontrolled asthma attack, lack of patient cooperation, uncorrected coagulopathy, recent myocardial infarction, unstable cervical spine, impaired neck mobility, and the need for a large tissue specimen.
19. Is sedation important during a flexible bronchoscopy procedure?
Yes, the goal of sedation is to improve the patient’s comfort during the procedure. In addition to risks of arrhythmias and fluctuations in blood pressure related to the procedure, airway manipulation during bronchoscopy may lead to coughing, hypoxemia, vomiting, bleeding, laryngospasm, and bronchospasm. All of these responses can affect the outcomes of the procedure. Therefore, adequate sedation is an essential part of the procedure.
20. What is BAL, and when is it indicated?
BAL stands for Bronchoalveolar lavage. It is used to obtain specimens from the alveolar region of the lung.
21. When is rigid bronchoscopy indicated?
Although the role of rigid bronchoscopy (RB) has declined, it remains an invaluable tool for the control of a compromised airway, massive hemoptysis, silicone stent placement, and for removing asphyxiating foreign bodies. The primary indication for rigid bronchoscopy is for managing a central airway obstruction.
22. What is the difference between BAL and bronchial washings?
Bronchial washings are generally obtained for the cytological examination of cancer and for microbiological analysis to diagnose mycobacterial or fungal infections. Unlike BAL, bronchial washings are obtained from the large airways.
23. What should a respiratory therapist consider regarding oxygen delivery during thermal ablation?
During the application of “hot therapies” (thermal ablation) like a laser, electrosurgery, or argon plasma coagulation, the FiO2 should always be maintained below 40% to prevent endobronchial ignition.
24. What are endobronchial stents used for?
Stents are devices designed for internal splinting of the airway lumen. Airway stents have been used to help reduce airway obstruction from malignant or benign processes that compress the airway from the outside. Airway stenting can offer immediate relief of acute respiratory distress, allow successful extubation, and may prolong survival.
25. What is the definition of bronchoscopy?
It is the process of passing a bronchoscope into the airways for either diagnostic testing or therapeutic purposes.
26. What are the four types of bronchoscopy?
Flexible bronchoscopy (FB), Rigid bronchoscopy (RB), Diagnostic bronchoscopy (DB), and Therapeutic bronchoscopy (TB)
27. A rigid bronchoscopy is preferred under what conditions?
It is preferred when the patient is under deep sedation with muscle relaxation.
28. What are the risks of flexible bronchoscopy?
Arrhythmias, fluctuations in blood pressure, and airway manipulation during bronchoscopy may lead to coughing, hypoxemia, vomiting, bleeding, laryngospasm, and bronchospasm.
29. What maneuver is used if the patient becomes over-sedated during a bronchoscopy procedure?
The chin-lift and jaw-thrust maneuver may be used.
30. What is recommended to prevent the patient from slipping into deep sedation?
Capnography monitoring while performing flexible bronchoscopy under moderate sedation is recommended.
31. What does flexible bronchoscopy monitoring consist of?
You must keep track of patient responses to verbal commands or spontaneous movements. Their chest movement may continue despite a near-total obstruction of the airway. There should be continuous cardiac, blood pressure, and pulse oximetry monitoring. Capnography should be used to monitor and prevent the patient from entering deep sedation.
32. What are the types of therapeutic bronchoscopy?
Rigid bronchoscopy, thermal ablation of the endobronchial lesion, brachytherapy, cryotherapy, and endobronchial stents.
33. What is the major indication for rigid bronchoscopy?
Managing central airway obstructions
34. What are the three types of thermal ablation of an endobronchial lesion?
Endobronchial electrocautery, argon plasma coagulation (APR), and laser photocoagulation.
35. What are the risks of thermal ablation of an endobronchial lesion?
Improper use of thermal modalities can lead to perforation of the airway, vascular structures, or the esophagus.
36. What are the complications of thermal ablation of an endobronchial lesion?
Hypoxemia, pneumothorax, and bronchopleural or bronchoesophageal fistula.
37. What are the contraindications of thermal ablation of an endobronchial lesion?
Refractory hypoxemia and extrinsic compression of the airway without an endobronchial lesion.
38. What is the relation between flexible bronchoscopy and an endotracheal tube?
You can use a flexible bronchoscope to place an ET tube through the mouth or nose. It allows for awake intubations with topical anesthesia. It is used in patients with cervical injuries where immobilization of the neck is crucial. It may also help identify causes of acute hypoxia and help remove secretions from the airway. It is limited to the experience of the operator, and there must be patient cooperation.
39. What is the respiratory therapist’s role in bronchoscopy before the procedure begins?
Respiratory therapists help identify the potential need for bronchoscopy (retained secretions or foreign body removal). They verify the physician’s order or protocol and review the patient’s record for contraindications (excessive clotting times), hazards, and informed consent. They prepare/ensure the proper function of equipment. They outline a plan for adequate oxygenation during the procedure. They evaluate the patient for bronchospasm and administer aerosolized bronchodilators if required. They assist nurses in the application of topical anesthetics.
40. What is the respiratory therapist’s role in bronchoscopy during the procedure?
Respiratory therapists monitor the patient’s vital signs (including capnography). They help identify and respond to adverse reactions and administer oxygen as needed. They provide proper positioning of the patient and assist with the use of accessories (bite block, oral airways, nasopharyngeal tube, biopsy forceps, brushes, etc.) They set up instruments for rigid bronchoscopy and silicone stents and help place chest tubes or ET tubes in emergency situations.
41. What does a respiratory therapist do during a bronchoscopy of a patient who is receiving mechanical ventilation?
Respiratory therapists help determine the appropriate length and diameter of the ET or tracheostomy tube. They ensure that the bite block is in place to avoid equipment damage. They adjust ventilator settings for safety reasons and oxygenation purposes and then return settings back to the patient’s pre-procedure settings.
42. What are the main complications and risks of a bronchoscopy procedure?
Bleeding, infection, bronchial perforation, bronchospasm, laryngospasm, and pneumothorax.
43. The endoscope reaches what generation of bronchi?
44. What is a rigid tube?
It’s an open metal tube with a distal light source and port for oxygen/ventilating equipment.
45. Who uses the rigid tube?
Otorhinolaryngologists and thoracic surgeons
46. What type of bronchoscope do respiratory therapists most often assist with?
47. Which bronchoscope can access very small airways?
48. What are the channels in a flexible fiberoptic bronchoscope?
Light transmission, visualizing, and multipurpose open
49. Who uses the flexible fiberoptic bronchoscope?
The pulmonologist, along with assistance from a respiratory therapist.
50. What is the most common method of anesthesia during a bronchoscopy?
The use of a topical anesthetic is the most common.
A bronchoscopy is a critical procedure that has revolutionized the way we diagnose and treat various pulmonary disorders. Through this article, we aimed to provide a comprehensive overview of the procedure and its importance in modern medicine.
Additionally, the practice questions presented in this article are designed to reinforce key concepts and enhance understanding, allowing healthcare professionals and students to develop a strong foundation for performing this procedure.
By staying up-to-date with advancements in this field and refining one’s skills, practitioners can continue to improve patient care and contribute to the ongoing evolution of pulmonary medicine.
John Landry, BS, RRT
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
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- Paradis TJ, Dixon J, Tieu BH. The role of bronchoscopy in the diagnosis of airway disease. J Thorac Dis. 2016.